Many many moons ago, I worked in a Pharmacy Call Center for a state insurance company.
I had moved from medical coding/billing to medical call center and on to pharmacy call over the span of 5 years, so I prided myself on having some common sense when it came to how Doctor’s offices/staff and Pharmacy staff “usually” operated. However, it also clued me in to how patients (a.k.a. clients) would try to game the system.
One of my favorites was the repeat caller/patient/client who called in on a monthly basis in order to request a “vacation override” on a narcotic. If you’re not familiar with the idea – our company allowed patients to call in to request an early refill for a monthly medication (whether blood pressure med, anti-psychotics, anti-depressants, etc.) if the patient was “going on vacation and needed to take the medication with them, but there was a viable chance the medication could run out while they were out of the area.” The script could be filled up to two weeks early, but was usually limited to once every six months.
With this in mind, we also had patients who would “doctor shop” – basically making appointments with multiple doctors to have the same medication prescribed without the doctors being aware.
Combine these two practices and; if you have a semi-intelligent patient, this could be a recipe for one hell of a drug supply ring successfully paid-for-in-full by the insurance company.
Every Pharmacy Rep had been warned to watch for these red flags during training and we were even given actual examples from the system to show us what we would see and who to contact when it happened. When – not if.
Imagine, if you will, the following exchange with Ms. Narcotic-On-Vacation (Narc):
Me: Thank you for calling MEDPharm101(not really! LOL)
Narc: Hi, my name is Narc, ID#123abc and I need a vacation refill on my Vicodin.
Me: Thank you Ms. Narc – can I ask you to confirm your DOB for me.
Narc: Sure it’s Jan 1st, 1899.
Me: Thank you, and I understand you need a vacation fill for your Vicodin? Let me pull up that information.
At this point, if my system had a klaxon alarm, my ears would have been bleeding. Red Alert, Red Flag, take cover and call Superman!
Me: Ms. Narc, I’m seeing in the system that you asked for a vacation refill last month on your Vicodin, is this correct?
Narc: Yeah, I keep running out, the doctor’s supposed to up my dose, but hasn’t done it yet.
Honestly, if the doctor had changed the script to a higher dose – if probably would have killed an elephant, but what do I know?
Me: All right, Ms. Narc – may I ask you to hold for just a moment while I get that started for you?
Narc: (totally bored by now) Yeah, sure.
I put Ms. Narc on hold and frantically flag down my Floor Manager. I show her the whole history – Ms. Narc apparently had not one – not two, doctors writing scripts for her; she had a total of SIX doctors writing scripts for the same high dosage Vicodin and was refill all of them religiously on a two week cycle. The account had been flagged previously and she hadn’t been able to fill anything in about two months. We were betting her second-hand sales were starting to get a little slim now that her supply chain was running out. However, we couldn’t arbitrarily cut her off and were running out of reasons to not refill the script.
Then something she’d said to me flashed like a light bulb over my head – she’d said the doctor needed to change her script! Well – we need an authorization from the doctor’s office to accommodate that a change in narcotic scripts! We’ve got a reason to shut this one down!
Fist bump the Floor Manager and she hovers nearby in case this goes belly up on me.
Me: Ms. Narc? Thank you so much for waiting, I’m sorry that took so long. Because you mentioned a change in the script, I went through our authorizations from your doctor’s office to see if anything had been sent through for you. Unfortunately, I wasn’t able to find anything authorizing the change in script – so I reached out the doctor’s office for a new script. They weren’t aware of any new changes in your script, so they need to call you to set up an appointment to come in for some lab work in order to change your medication. This also means that, without the doctor’s authorization, I can’t release your next refill early.
Now keep in mind – I haven’t done anything of the sort – the Authorizations Dept would take care of contacting the doctor’s office after I get off the call.
Narc: (somewhere between aghast and enraged) You did what?? Who the H-E-double hockey sticks told you to do that??
Me: I’m sorry, Ms. Narc – but that is normal procedure with a change in script on a narcotic. The doctor’s office should be giving you a call shortly in order to set up a good time for you to come for your lab work. I’m so sorry I couldn’t help you with that refill – but is there anything else I can help you with today?
Narc: (spluttering, but not able to do a stinking thing about the situation, through clenched teeth) No thank you, I think you’ve helped quite enough.
*click*
I am grinning ear-to-ear and my Floor Manager’s doing a happy dance next to me. I send the ticket to Authorizations outlining what happened. Now here’s where it’s gets even better! Now that Authorizations is taking over – they can contact ALL of the doctors on her file to confirm a script change and “alert” them that she’s doctor shopping. This will effectively shut down her ring and black flag any new scripts being paid by the insurance company.
Extra for me? I got a nice bonus check and a Thank You letter from the Head of the Pharmacy Call Group.
submitted by /u/LadyGrey1174
[link] [comments]
